The efficacy of women's substance abuse treatment is well documented (Morash and Bynum, 1995; Falkin et al., 1994; CASA, 1996). There have been numerous books, articles, and studies supporting the need for gender-specific treatment for women. Visionaries such as Stephanie Covington have made a tremendous difference to the depth and scope of chemical dependency treatment for women of all ages. Issues of abuse and trauma, the core work for many women, became more readily approachable in the absence of men. Creating a safe environment in which to process that work was the driving force behind the foundation of the Center for Women's Recovery at the Hanley Center, where an all-female staff in a supportive atmosphere has proven to be very effective.

With that in mind, at the Center for Men's Recovery, we began to explore the possibility that gender-specific treatment may benefit men as much as it has women. Men had been the focus of the original residential treatment programs, but not much had changed over the past 50 years. The outcome statistics for traditional treatment are sparse and varied. Aggregate studies have shown abstinence rates of 40 percent after one year, and 33 percent after two years (Hoffman & Harrison, 1991), leaving 60 to 70 percent of treatment participants returning to active use. Long-term sobriety, therefore, was never a guarantee of treatment.

Finding a way to help more men achieve and maintain recovery while staying focused on the time honored 12-Step philosophy became our quest. An introduction to Stephen Andrew, LCSW, LADC, co-founder of the Men's Resource Center of Southern Maine, became the turning point of that quest.

An environment of risk

Traditionally, in treatment for males, the issues specific to gender were not addressed. These were the issues that often led to recidivism: inability to communicate, isolation and anger. As we began to study the available literature, we became aware there were some chilling statistics that formed a foundation for the need for male-specific treatment:

• The majority of children abused, neglected, and murdered are boys (Kipnis, 1999).
• Most of the children in foster-care, shelters, and juvenile institutions are boys (Kipnis, 1999).
• 75 percent of student suspensions, expulsions, grade failures, special education referrals, school violence casualties, and all other assault victims are boys (Kipnis, 1999).
• 70 percent of suicides are boys/men (Center for Disease Control 2006).
• 75 percent of teenage suicides are boys (Kindlom and Thompson, 1999).
• 80 percent of the homeless are boys/men (2006 National Alliance to End Homelessness).
• 70 percent of drug addicts/alcoholics are men (Powell, 2003).
• 80 percent of homicide victims are men (U.S. Dept. of Justice, 2003).
• 93 percent of prisoners are men (U.S. Dept. of Justice, 2003).
• 99 percent of executed prisoners are men - in the last decade 700 men and 10 women (U.S. Dept of Justice, 2003).

Looking at these statistics led us to further examine the underlying causes, as well as how men in the grip of addiction are affected by those causes. Within moments of being born, males are treated with less affection than females. Studies have shown that a newborn baby covered with a blue blanket will get touched less and spoken to in a firmer voice than the same baby in a pink blanket (Greenberg, 1979). Gender-stereotyping behavior from adults is endemic, even from those sensitive to gender issues (Kivel, 1999). This sets the stage for the induction to the "Boy Code," in which emotions need to be kept in check, violence is an acceptable response to emotional upset, self-esteem relies on power, and that all "feminine" qualities must be rejected (Pollack, 1999). Boys may become starved for attention and put down as "sissies" if they cling and clamor for the closeness they need (Goldberg, 1976). Boys are traditionally taught to stuff all emotions through the often heard, "Big boys don't cry," or the more frightening, "I'll give you something to cry about." These early lessons teach them that it is not okay to emote, so all emotion is stifled (David and Brannon, 1976). 

Men are conditioned to not feel or express pain, grief, or hurt. The feelings of love, joy, and excitement also can get numbed. Anger, though, seems to be permitted and encouraged. Anger is cultivated through team sports where the goal is to "beat" the opponent as severely as possible. Boys learn that men are expendable, a commodity readily traded for "God and country" (Keen, 1991). Many a five-year-olds' life goal is to become a soldier, to fight. As boys grow into teens they can easily become engulfed in a "Culture of Cruelty" (Kindlom and Thompson, 1999), in which they are either victims, perpetrators, or witnesses of daily violence and humiliation. Boys are socialized to fear each other. This is the truest definition of homophobia, the fear of men, which is rampant in our culture.

Boys are taught that their emotional needs cannot be met in their relationships with each other (Real, 1997), that to be too close to another boy may leave them labeled as "gay," and in that pubescent maelstrom, such a label is social suicide. This creates a vacuum in which boys need an emotional connection but may not have the social skills to obtain it in a healthy manner (Pollack 1999). Parental guidance in this period is often fragmented at best. Fathers are often absent, either physically through divorce or work, or emotionally through their own shortcomings. Mothers can be extremely protective or overly dependent (Ackerman, 1993). William Pollack (1999) states that "at a very young age a boy may feel emotionally abandoned." Few boys survive childhood without some form of physical or emotional trauma, either resulting from the aggression of their peers, or the emotional separation from their parents (Pollack, 1999). Boys may learn to trust no one, that they "should" know how to take care of everything, how to fix everything.  

It is not surprising, given this information, that so many men seek comfort with alcohol and drugs, and for many, that initial comfort becomes a physical addiction. The void created by the trauma of boyhood can be filled, even if temporarily, by chemical enhancement. Pain can be numbed, shyness can be masked, anxiety can be ameliorated. The need for connection without intimacy can be met. But what happens when the substances stop working, when the consequences of using them become too unbearable? The unthinkable act of asking for help can only be overshadowed by the inability to receive it when it is offered (Goldberg 1976).

Challenging belief systems: what is it like to be male?

This is the dilemma: How can we teach men, who are socialized to be incapable of sustaining trust, that their only hope of relief is to trust and to allow themselves to be come vulnerable with their peers? This was an anathema to their survival, and the transition could be difficult. In essence, by entering treatment, we are asking men to challenge the very core beliefs they have lived by. In our work we ask the question, "What is it like to be male?" The answers invariably include the following: lonely; isolative; armor-plated; judged; seen as a threat to women, children, and each other; aggressive; expected to perform, provide, and protect. When compared to what we ask of men in treatment - to be vulnerable; share emotions; take risks; cooperate; believe; accept other's ideas - it is easy to see how men could initially perceive treatment as threatening.

Our first goal, therefore, became to create an environment in which men could feel safe enough to allow themselves to open up to one other. The belief was that by creating a safe space, emotional movement would occur. This environment included having an all-male staff with which to interact, thereby breaking the cycle of relying on women to meet emotional needs (Goldberg 1976). It was important to examine the socialization process that was common to the western male. Five areas were outlined and educational modules were created to help the men in residential treatment understand the how and why of their behavior.

Educational modules

Being a Man. In this module we take a good look at our societal standards of "real" masculinity. Dovetailing with the work of Paul Kivel, we address the boxed-in stereotype that drives men's beliefs about themselves. We examine the roles that men are expected to fill, and the anxiety attached to those roles. We talk about the limitations of forcing ourselves to fit inside the box, and the incredible social price that is paid by those who dare to challenge the boundaries.

Family of Origin/Fathers. This module has its roots in Lucia Cappachione's (1999) work "Healing the Inner Child." We examine childhood messages and paint a picture of the dynamics that led to a life of addiction and isolation. We look at the role of fathers, and teach the men how they can begin to parent themselves if necessary. We use art and psychodrama to reinforce the work, which helps to tap into the unconscious, where many of our early traumas are stored.

Interpersonal Violence: Anger, Rage, and Control. The emotion most commonly identified by the men in our groups is anger. Anger is accepted and often expected from men in our society, yet it is destructive to the fabric of our culture when it is inappropriately expressed. We explore the distinction between the emotion of anger and the action of aggression, which is often blurred by early modeling. We take a look at rage, which is what many men think of when they talk about anger. We also address issues of power and control as it relates to interpersonal relationships. Normalizing anger, identifying it as a secondary emotion to fear and shame, and opening a dialogue, helps to begin the process of learning to express anger in a healthy manner. Conscious breathing, writing, talking, drumming, and dancing are some of the outlets that are discussed (Lee, 1993).

Sexuality. The connection between drug and alcohol dependence and promiscuity is apparent (Scneider, 1992), but beyond that there is an underlying cultural belief that men "should" know about sex, and a "real man" can always please his partner (Keen, 1991). Looking at sexual values and mores in a group setting often removes the bravado factor and allows the men to take an honest look at their beliefs. We address the issues of sexuality, sexual dysfunction, and sex addiction. Using scales developed by Patrick Carnes we help each man look at his history and gain an understanding of his own patterns.

Male Spirituality. This group seeks to engage all in safe, non-threatening and non-judgmental dialogue concerning spiritual matters. As the men discover that spirituality is all about connecting to life, and active addiction is all about disconnecting from life, the correlation of importance to recovery becomes more and more clear. Spiritual development requires that each man develop an ability to trust and eventually to rely on elements that are outside of himself. In stark contrast, men are taught from a very young age to be independent and self-sufficient and, though this is often an indirect correlation, men tend to conclude that to rely on anyone or anything else is a form of weakness, which will be shortly exploited (Goldberg, 1976). Overcom-ing this requires an environment where vulnerability and trust are redefined as strengths rather than weaknesses and acts of courage rather than cowardice. As this is developed men become more open to allowing themselves to clear the cobwebs from their spirits, and begin to experience life and peace.

Motivation to move

As important as these modules are, they play only one part in the successful treatment of men at the Hanley Center. Another critical component has been the adoption of Motivational Interviewing (MI) as an instrument for change. First introduced specifically for working with the chemically dependent population by Drs. William Miller and Steve Rollnick (1992), MI gives every man the opportunity to find his own intrinsic reasons to seek recovery. Using the skills learned through a series of extensive and ongoing training, the counselors at the Center for Men's Recovery have become more empathic listeners with the ability to reflect and guide their clients without the need for relationship damaging power struggles. Audio taping individual sessions, with client consent, provides an effective feedback loop for each counselor to check and continuously improve his adherence to the MI spirit. In supervision we are able to listen to our work, and hear how it reflects the plight and struggle of each man. Once a man's ambivalence has been resolved, he is more open to traditional education and therapies.

Other tools found to be effective include a readily available male spiritual counselor, utilization of pet-therapy, a labyrinth for walking meditation, art therapy, and regular team building experiential groups. An example of the experiential work is the "spider's web," in which all of the participants work together to pass through a giant bungee web. This exercise promotes trust, teamwork, communication, problem solving, and of course, fun. More subtle therapeutic aspects of this and other experiential exercises include addressing the discomfort many men feel in close proximity to each other. Another experiential group that has facilitated profound emotional movement is the "Trust Walk," in which each man is led blindfolded by a peer through an obstacle course. This activity requires complete trust, letting go of control, and faith. This work ties easily into 12-Step principles. The nature of these exercises encourages the men to step "out of the box" and to be vulnerable. This is a huge risk for a majority of the participants, and every effort is made to keep the environment safe.

Art therapy, psychodrama, and the use of film clips have also proven to have a positive effect in helping men explore their emotions. There is seldom a dry eye in the house following a viewing of the final scene from "Field of Dreams," for example. A simple movie clip can cut through the intellectual barriers that many men hide behind. Michael Gurian (2000) offers a host of therapeutic film suggestions in his book "What Stories Does My Son Need," many of which are perfect grist for a man's emotional mill.

In summary

The amalgamation of male-specific focus groups, an all-male staff, motivational interviewing, experiential therapy, in-house spiritual counseling, and holistic treatment planning with a 12-Step focus, seems to be having a viable impact on the treatment experience for the men who have sought help at the Hanley Center. We are collecting narrative exit interviews and are conducting outcome studies that will, I believe, support the efficacy of our approach. It is already obvious to those of us fortunate enough to work with our clients, that our approach is making their treatment experience far more enjoyable, profound, and effective than many of them imagined possible. And that, for now, is enough. 

References

Ackerman, Robert J. (1993). Silent Sons: A Book For and About Men. Fireside.

Andrew, Stephen. (1993). Courageous Men (audiotape). Spritwind Tape Series,

Andrew, Stephen. (1994). Anger: Rage or Passion? (audiotape). Spiritwind Tape Series.

Capacchione, Lucia, PhD. (1991). Recovery of Your Inner Child. Fireside: Simon and Schuster.

Carnes, Patrick. (1992). Out of the Shadows: Understanding Sexual Addiction. Hazelden.

CASA (Center on Addiction and Substance Abuse at Columbia University). (1996). "Substance Abuse and the American Woman." New York, New York.

Center for Disease Control (2006). www.cdc.gov

Covington, Stephanie, PhD. (1994) A Woman's Way Through the Twelve Steps. Hazelden.

David, D. & Brannon, R. (1976). The Male Sex Role: Our culture's blueprint of manhood, and what it's done for us lately. Addison-Wesley Publishing Company.

Goldberg, Herb, PhD. (1976). The Hazards of Being Male: Surviving the Myth of Masculine Privilege. Wellness Institute Inc.

Greenberg, S. (1979). Right from the Start: A Guide to Nonsexist Child-Rearing. Boston: Houghton Mifflin.

Gurian, Michael. (2000). What Stories Does My Son Need? Tarcher/Putnam, New York.

Falkin, G., Wellisch, J., Prendergrast, M.L., Kilian, T., Hawke, J., Natarajan, M., Kowaleswskis, M., and Owen, B. (1994). Drug Treatment for Women Offenders: A Systems Perspective. Washington, D.C.: National Institute of Justice.

Hoffman, N. & Harrison, P. (1991). The Chemical Abuse Treatment Outcome Registry (CATOR). Hazelden.

Keen, Sam, PhD. (1991). Fire in the Belly: On Being a Man. Bantam Books.

Kindlom, Dan, Ph.D. & Thompson, Michael, Ph.D. (1999). Raising Cain: Protecting the Emotional Life of Boys. Ballentine Books.

Kipnis, Aaron, Ph.D. (1999). Angry Young Men. Jossey-Boss Publishers,

Kivel, Paul (1992). Men's Work: How to Stop the Violence that Tears Our Lives Apart. Hazelden.

Kivel, Paul (1999). Boys Will Be Men: Raising Our Sons for Courage, Care, and Community. New Society Publishers.

Lee, John (1993). Facing the Fire: Experiencing and Expressing Anger Appropriately. Bantum Books.

Miller, William, PhD & Rollnick, Stephen, PhD. (2002). Motivational Interviewing: Preparing People for Change. The Guilford Press.

Morash, M. and Bynum, T. (1995). Findings from the National Study of Innovative and Promising Programs for Women Offenders. School of Criminal Justice, Michigan State University.

National Alliance to End Homelessness. (2006). www.endhomelessness.org

Pollack, William, PhD (1999). Real Boys: Rescuing Our Sons from the Myths of Boyhood. Random House.

Powell, David, PhD. (2004). Playing Life's Second Half. New Harbinger

Real, Terrence. (1997). I Don't Want to Talk About It. Scribner.

SAMHSA (1996). www.oas.samhsa.gov

Schneider, Burt (1992). The Cocaine Sex Connection: Understanding Our Sexual Acting Out. Hazelden.

U.S. Dept. of Justice. (2004). www.ojp.usdoj.gov/bjs. 

This article is published in Counselor,The Magazine for Addiction Professionals, October 2006, v.7, n.5, pp.32-36.

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